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En gendering leadership

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This is a case in which an employee encountered an ethical crisis. The organisation was responsible for commissioning healthcare, and it was as if her unconscious was demanding of her professional self: ‘are you going to give me your money or your life?’ Choosing ‘money’ would mean going along with what the organisation was demanding of her at the cost of others’ lives, while postponing the question(ing) of her life; choosing ‘life’ meant confronting the issues the organisation was facing; and resigning meant giving up on either choice.
This encounter between the ‘one alone’ approach of the organisation and the incompleteness of its responses to its citizen-patients reflected a radical non-rapport between the different ways-of-being of the organisation and of the citizen-patient as the organisation’s other, in which the organisation faced a lack experienced as a demand for something more that in this case it was refusing.
This paper considers how the current contractual arrangements between the organisation and its service-providers served the interests of the powers-that-be and examines the gendered assumptions built into these contractual arrangements. The paper considers how a different understanding of leadership would create ways of balancing interests that were en-gendering by working with the non-rapport inherent to the relation between the organisation and the lives of its citizen-clients. The paper will provide some Lacanian background to this way of understanding organisation and consider its implications for the ethical crisis that the contractor faced.

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En gendering leadership

  1. 1. ‘Your Money or Your Life’: en-gendering leadership Philip Boxer BSc MBA PhD OPUS Conference 2018 November 15th 1. The Case 2. Symptoms of Maladaptation 3. The view from NHS England 4. The citizen-patient as boundary object 5. The relation to ‘lack’ aka incompleteness 6. In Conclusion – how hard can that be? 1 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  2. 2. The Case 2 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  3. 3. Context to the case • A Clinical Commissioning Group (CCG) within the UK’s National Health Service (NHS). • My client had been employed by the CCG to focus on particular health conditions with the goal of delivering improvements in quality, innovation, productivity and prevention (QIPP). • My client reported directly to the Deputy Director of Commissioning (DDoC), who reported to the CCG’s General-Practitioner-led Board. 3 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike • To be effective, my client • had to work in support of the Clinical Leads working on behalf of the Primary Care GPs for the particular conditions being focused on by the CCG. • also had to work within the constraints imposed by the CCG’s Head of Information (HoI) who reported through a Chief Financial Officer to NHS England and who was also Head of the Programme Management Office (PMO), which tracked delivery of the CCG’s 5 year Strategic Plan.
  4. 4. The demand arising from patients • The QIPP* goals for respiratory conditions had been set by comparing the Clinical Commissioning Group’s (CCG’s) average performance with that of a grouping of other CCGs with comparable catchment profiles. • The goal was set by assuming that the CCG’s below-average performance could be improved to the average. 4 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike • At his job interview, my client had described an approach to QIPP that involved • stratifying patients’ conditions, ranging from simple to complex; and • examining the interactions of the healthcare ecosystem with an individual patient over time. • The Deputy Director of Commissioning (DDoC) liked the approach. * Delivering improvements in Quality, Innovation, Productivity and Prevention
  5. 5. The Challenge of the Case1 • Stratified Analysis of patients in terms of the complexity of their condition • Showed that breathlessness could arise not only from respiratory conditions but from other comorbidities such as coronary heart disease, chronic obstructive pulmonary disease, cancer and neurological conditions. • Showed the need to diagnose early, focus on breathlessness and manage differently the patients identified as high users of the healthcare ecosystem. 5 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike • But the acute data was not organised around patient timelines, the data being organised around treatments because of the acute system’s focus on the cost of treatments. • My client was able to extract data from the information systems and reorganise it by patient timeline for the preliminary analysis. • And the CCG’s information department, which reported to the Head of Information (HoI), was not prepared to take responsibility for performing a reorganisation of data in this way.
  6. 6. The Challenge of the Case2 • No data existed for examining the timelines of the interactions by patients with complex conditions between the primary and acute care systems. • each practice’s data being held in its own information silo. 6 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike • It was therefore proposed to do this analysis on a sample basis. • It was proposed this be done on the outlier practice (top-right), which happened to be the practice of the Clinical Lead for respiratory conditions.
  7. 7. Resistance aka conservation of identity • At this point the Clinical Lead objected to the whole sampling approach, • citing that GPs would be insulted by a study that sought to identify issues that they were already aware of in their practices, and refused to sign off on the analysis. • The Head of Information then added that the PMO would not recognise any data analysis not done by them, having previously refused to take responsibility for this type of analysis. • The new Director of Commissioning (DoC), who had recently replaced the previous DoC and who had been supportive of the sampling approach proposed by my client, was now faced with pushback from both the PMO and the Clinical Lead. • She requested my client to revert to the approach that had been used prior to his recruitment by the DDoC and complete the work in an impossibly short time. 7 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  8. 8. The Ethical Crisis for my client • It was as if his unconscious was demanding of his professional self: ‘are you going to give me your money or your life?’ • Should he stay and get paid for serving his time doing an impossible task? Choosing ‘money’ would mean going along with what the CCG was demanding of him at the cost of patients’ quality of life and devaluing his own. • Should he try and fight with the larger system based on all the work he had done up to that point? Choosing ‘life’ meant risking being fired by confronting the issues the current organization was implicitly choosing not to face. • Should he resign? Resigning meant giving up on what felt like an unequal struggle with the powers-that-be – the resistance of the HoI/PMO and the Clinical Lead. 8 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike • It is possible to examine this case situation in terms of what my client might have done ‘wrong’ in his role. • This paper considers how my client was never going to succeed with the CCG’s current approach to governance. • The primary issue was not about how my client was taking up a role in the life of the CCG, but rather how the CCG was taking up a role in the lives of the citizen- patients for whom it had a duty of care.
  9. 9. Symptoms of Maladaptation 9 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  10. 10. Maladaptation by an organization within an ecosystem • Monothematic dogmatism • depth is captured once and for all. It is a superficial satisfaction of the need for overriding values to guide behavior in turbulent environments. • Hence, dogma becomes the normative base for distinguishing right from wrong, good from bad, goals from noxiants. • Polarisation • in-group/out-group dynamics. The tendency at the group level is autonomy, exemplified in each group's striving to become more distinct and independent from others. • The tendency at the individual level is a need to belong to a larger whole, satisfied through the strong affiliation with an in-group. • Stalemate • the suffocation or frustration of progress, movement, growth, or development for the whole system. • It involves an inability to articulate, design, and, in particular, pursue sometimes even the most mechanical ends of the whole system. • There seems to be an obsessive concern with means at almost complete expense to ends, • so much so that stalemated social systems come as close to being purposeless as can be expected from a social system See Baburoglu, O. N. (1988). "The Vortical Environment: The Fifth in the Emery- Trist Levels of Organizational Environments." Human Relations 41(3): 181-210. 10 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  11. 11. The view from NHS England 11 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  12. 12. The limitations of Primary Task • The CCG’s primary task had been defined as being one of commissioning the availability of a repertoire of possible services and treatments within the healthcare ecosystem based on aggregated measures of healthcare demand • in effect defining the catchment in terms of markets for different kinds of healthcare treatment. 12 Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. They are clinically- led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. NHS Clinical Commissioners. (2018). "About CCGs." NHS Confederation Retrieved 10/30/2018, 2018. • Meanwhile, at the level of individual patients, the healthcare ecosystem was needing to support many simultaneous care pathways aka networked organisations, • each of which needing to orchestrate and synchronise services and treatments in different ways for different citizen-patients’ situations Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  13. 13. The need to respond to citizen-clients one-by-one • The result was that the CCGs needed to respond to the nature of each person’s condition and circumstances • So that the CCGs could not rely on a stable definition of its primary task, but had to continually adapt and respond to the demands and expectations being placed on them, 13 “such as in 2014’s Leading local partnerships, […] driving new and innovative models of care by putting the patient at the heart of the system, and improving the health and wellbeing of local people […] in 2015 with Transforming healthcare in England’s core cities […] and in 2016 with Delivering a healthier future […] showing how CCGs are addressing health inequalities, the prevention agenda and striving for parity of esteem between mental and physical healthcare.” NHS Clinical Commissioners. (2016). "The future of commissioning." Retrieved 10/30/2018, 2018. • The resultant accelerating proliferation of primary tasks meant that in practice the CCGs could not rely on its organisation as a whole being defined by the primary task of commissioning for aggregated measures of healthcare demand aka healthcare markets. • It had to be able to commission in a way that enabled different citizen-patients to be responded to differently through the life of their conditions one-by-one. Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  14. 14. Source: Fig 2-1 on the Management Challenge: Systems Engineering Guide for Systems of Systems, OSD, Version 1.0 August 2008. A collaboration between actors aka a networked organisation Supporting care platforms Superposition of many care pathways aka networked organizations Simultaneous networked organizations Support The CCG has to be able to commission many different care pathways at the same time Responding to clients one-by-one: each care pathway aka networked organisation defines a ‘quantum’ state of the healthcare ecosystem* • A networked organisation is a collaboration, the nature of which will be determined by the way its actors understand what its patient wants, i.e. what is the patient’s demand. • The actors participating in the networked organisation define the way they want their collaboration to be supported by the platform. • Its actors can be spread across multiple organizations within the healthcare ecosystem. • For this to be possible, the supporting platforms have to be able to support multiple simultaneous networked organisations aka ‘superposed’ collaborations. Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike 14 * Boxer, P. J. (2014a). "Leading Organizations Without Boundaries: 'Quantum' Organization and the Work of Making Meaning." Organizational and Social Dynamics 14(1): 130-153.
  15. 15. The challenge facing the CCG • The challenge facing the CCG is thus between being an organization • defined as a hierarchy; or • defined by its support for many concurrent networked organizations. 15 * Boxer, P. J. (2014a). "Leading Organisations Without Boundaries: 'Quantum' Organisation and the Work of Making Meaning." Organizational and Social Dynamics 14(1): 130-153. Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike “[…] traditional models of care need to change […] where some of the day-to-day transactional elements of commissioning may transfer to what are becoming collectively described as accountable care systems, taking direct responsibility for day-to-day care for a defined population within an area […] in the future, […] it should be locally defined and driven..” NHS Clinical Commissioners. (2016). "The future of commissioning." Retrieved 10/30/2018, 2018. • This presents a challenge to leadership based on vertical accountability alone. • This requires a move from unipolar to multipolar forms of governance, • moving from a vertically-dominant form of governance defined by accountabilities to a pre-existent model • towards a horizontally-dominant form of governance defined by horizontal linkages between networked organisations accountable to current local situations. e.
  16. 16. The citizen-patient as boundary object* The patient’s condition constituted a boundary object because while from the clinician’s side of the boundary, it represented a condition needing treatment, from the patient’s side, it was something s/he had to find ways of living with within the context of his or her life. 16 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike *Akkerman, S. F. and A. Bakker (2011). "Boundary Crossing and Boundary Objects." Review of Educational Research 81(2): 132-169; Leigh-Star, S. and J. R. Griesemer (1989). "Institutional Ecology, 'Translations' and Boundary Objects: Amateurs and Professionals in Berkeley's Museum of Vertebrate Zoology, 1907-39." Social Studies of Science 19: 387-420. Hirschhorn, L. (2018). "Beyond BART (Boundaries, Authority, Role and Task): Creative Work and the Developmental Project." Organisational & Social Dynamics 18(1): 41-61. The patient as boundary object challenged the BART paradigm insofar as it took the CCG beyond its definition of itself in terms of its primary task.
  17. 17. Distinguishing object-referenced from subject-referenced meanings • The Head of Information (HoI) was arguing that my client was using language that had subject-referenced meanings not established by the CCG’s accountability hierarchy, or at least not without following the forms of analysis introduced by my client, on which they had been based. 17 meaning that can be established independently of the speaker by a community of listeners aka inter-subjectively agreed meaning that can only be established by reference to the speaker’s experience of their experiencing aka vague Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike ‘objective’ aka independent of the speaker because it is as if ‘facts’ speak for themselves degrees of vagueness Subject-referenced characterising Object-referenced categorising invariably vague* aka wholly dependent on the relation to the speaker because rooted in the speaker’s experiencing * A characteristic of what is held to be acritically indubitable. See Peirce, C. S. (1905). "Issues of Pragmaticism." The Monist XV(4): 481-499. Boxer, P. J. (2019b). "Working with the 'irritation of doubt': the place of metaphor." Socioanalysis submitted for publication.
  18. 18. Accountability hierarchy dependent on establishing inter-subjectively agreed meanings for signifiers • The CCG’s accountability hierarchy (and the PMO in particular) described an established inter-subjectively-agreed way of fixing meaning aka way of ‘organising’ signifiers with its way of referring to an object-referenced signified 18 ↑ 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 The direction of the arrow here indicates that the signified is subjected to the signifier* Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike 𝐴𝑐𝑐𝑜𝑢𝑛𝑡𝑎𝑏𝑖𝑙𝑖𝑡𝑦 ℎ𝑖𝑒𝑟𝑎𝑟𝑐ℎ𝑦 𝑥 = ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′𝑣𝑖𝑟𝑡𝑢𝑎𝑙′ ′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠 → 𝑡ℎ𝑒 ′𝑎𝑐𝑡𝑢𝑎𝑙′The way of ‘reading’ is privileged ≡ ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 𝑎𝑛 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑There has to be a shared ‘actual’ *Based on a structuralist way of understanding the relation between signifier and signified, see Miller, J.-A. (2011). "The Economics of Jouissance." Lacanian Ink 38 (Fall 2011): 6-63.
  19. 19. The presumption of an unconscious ‘below-the-surface’ with object-relations theory, the unconscious object-signifier is a way of being in relation to a signified • We speak of there being a fixing of libidinal investment in the sovereign ego’s way of being in relation to a subject-referenced signified aka ‘a radically unconscious’ 19 ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 ′𝑏𝑒𝑙𝑜𝑤 − 𝑡ℎ𝑒 − 𝑠𝑢𝑟𝑓𝑎𝑐𝑒′ The assumption of an unconscious ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 The way of being in relation to a signified has an organisation… ≡ ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑠𝑜𝑣𝑒𝑟𝑒𝑖𝑔𝑛 𝑒𝑔𝑜 𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 … which, as a sovereign ego, subjects the signified Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike Miller, J.-A. (2000). "Paradigms of Jouissance." Lacanian Ink 17: 8-47.
  20. 20. Unconscious valency A ‘fit’ between the fixing of libidinal investment in the sovereign ego’s way of being and the support provided by an accountability hierarchy • My client was introducing a different way of ‘organising’ signifiers that had not been inter-subjectively agreed with the HoI/PMO, albeit one that had formed the basis of his having been recruited by the DDoC. 20 ↓ 𝑀𝑦 𝑐𝑙𝑖𝑒𝑛𝑡 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑠𝑜𝑣𝑒𝑟𝑒𝑖𝑔𝑛 𝑒𝑔𝑜 𝑎 𝑟𝑎𝑑𝑖𝑐𝑎𝑙𝑙𝑦 𝑢𝑛𝑐𝑜𝑛𝑠𝑐𝑖𝑜𝑢𝑠 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike ↓ Τ𝐻𝑜𝐼 𝑃𝑀𝑂 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′ 𝑣𝑖𝑟𝑡𝑢𝑎𝑙′ ′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠 → 𝑡ℎ𝑒 ′𝑎𝑐𝑡𝑢𝑎𝑙′ ≢ … did not fit with the existing accountability hierarchy as represented by the HMI/PMO ↓ 𝐷𝐷𝑜𝐶 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 𝑎𝑛 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 DDoC’s unconscious valency DDoC’s unconscious valency… Boxer, P. J. (2017a). "Working with defences against innovation: the forensic challenge." Organizational and Social Dynamics 17(1): 89-110. • This rendered my client’s meanings subject-referenced and was the means by which the accountability hierarchy defended itself against innovation.
  21. 21. The relation to ‘lack’ aka incompleteness 21 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  22. 22. Need for more clinical research Reinforcing Consequence ‘impossible desire’ The impossibility around which these frames oscillate… each frame’s relation to incompleteness 2: Intervention should be based on directly experienced truths Outcomes in this case clinical consultation A GP’s counter- narrative Framing Demand for more consultations http://www.asymmetricleadership.com/2007/07/dilemmas-as-drivers-of-change/ Dilemmas and the relation to ‘impossible desire’ aka incompleteness 22 So what in clinical practice? Flipping Consequence So what knowledge am I missing? Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike The accountability hierarchy’s dominant Framing Framing consistency with its a priori assumption Outcome Process 1: Intervention should be based on scientifically established truths Knowledge research
  23. 23. The relation to ‘lack’ The subject is ultimately subjected to a radically unconscious relation to ‘lack’, with the effect of reversing the direction of the arrow • En-gendering leadership is defined as leadership that works explicitly with this non-rapport between consistency and incompleteness, • non-rapport because any taking up of a way of being consistent will always be limited by its incompleteness – by an ‘irritation of doubt’. 23 ‘lack’ ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↓ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 → 𝑎 a 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 →  Being subjected to the relation to ‘lack’ Consistency All of the CCG’s behaviors are subject to the CCG’s accountability hierarchy Incompleteness Only some behaviors in the citizen- patient’s situation may be subject to the CCG’s accountability hierarchy Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↑ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 Sovereign ego Boundary object Boxer, P. J. (2019b). "Working with the 'irritation of doubt': the place of metaphor." Socioanalysis submitted for publication.
  24. 24. Working with the ‘irritation of doubt’ any taking up of a way of being consistent will always be limited by its incompleteness • My client, in working with the gaps in the way the ecosystem was relating to its clients was opening up a demand on the CCG for en-gendering leadership • Leadership in which leadership’s way of ‘reading’ needed to be open to an ‘irritation of doubt’ about its current efficacy, • making it possible for there to be learning about the ‘actual’ gaps in the way patients were being treated 24 ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↓ 𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′𝑣𝑖𝑟𝑡𝑢𝑎𝑙′ → 𝑑𝑜𝑢𝑏𝑡 ′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠→ ′𝑎𝑐𝑡𝑢𝑎𝑙′ 𝑔𝑎𝑝𝑠 … means being subjected to the ‘irritation of doubt’ triggered by encountering ‘actual’ gaps ↓ 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔 ↓ 𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 → 𝑎 a 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 → Being subjected to the relation to lack… ‘lack’ Boundary object Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  25. 25. primary task primary risk domain of relevance Horizontal linkages to particular multi-sided situations Incompleteness made present by a patient situation The CCG’s Consistency defined by a prior relation to the domain of relevance Vertical accountability to one-sided model En-gendering leadership Maladaptation arises from the conservation of an existing form of consistency and a refusal to take up a relation to its incompleteness • In order to address the inherent non-rapport between the consistency of the accountability hierarchy and the life of the citizen-patient, the incompleteness presented by the particular situation of the patient must be addressed. • En-gendering leadership requires that the patient as boundary object brings a particular collaboration into being, aka a networked organization, relating the current consistencies of suppliers’ offerings to the incompleteness that the patient situation makes present. Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike
  26. 26. In Conclusion – how hard can that be? The en-gendering of the relation to boundary objects allows us to understand the radical difference between hierarchy and networked organisation in terms of their different relation to incompleteness, which goes further than just recognising the incompleteness of existing forms of consistency. It involves taking up a relation to the incompleteness per se made present by each ‘other’ client encountered one-by-one at the edges of an organisation, in such a way as to drive the learning and adaptation of the ecosystem within which it is working. 26 Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike

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